No 3 (2017)

The problem of the etiology and pathogenesis of acute obstructive pyelonephritis (OOP) remains one of the challenging issues of modern urology. Etiological agents of pyelonephritis can be both gram-negative and gram-positive opportunistic bacteria mostly belonging to the normal flora in humans. The generally accepted diagnostic work-up involves a bacteriological testing of not pelvic urine, but of bladder urine collected by a transurethral catheter or midstream specimens of urine collected from the patients. The aim of our study was to compare the microbiota of bladder and pelvic urine in patients with OOP. Materials and methods. The study comprised 72 sequentially selected patients (12 men and 60 women) with OOP associated with ureteral stones. Mean age of patients was 53.7±0.5 years. All patients underwent bacteriological examination of the bladder urine collected by a transurethral catheter and pelvic urine obtained after relieving stone-related ureteral obstruction. Urinary diversion was performed using j-j stent and PCN in 64 and 8 patients, respectively. Preoperative prophylactic antibiotics were administered routinely. Bacteriological testing of urine was carried out using an extended set (9-10) of culture media. Empirical antibiotic therapy was initiated only after the restoration of urine outflow from the kidney and continued for 5-6 days until the availability of bacteriological testing results. Results. Levels of bacteriuria with Enterobacteria, gram-positive pathogens and NAB in two urine samples did not differ significantly (p>0.05). There was a wide range of bacteriuria from 101 to 106 CFU/ ml of most microorganisms except @Proteus spp., S. aureus. In bladder urine, the rates of bacteriuria of ≥104 CFU/ml for E. coli, Klebsiella spp. and Proteus spp. were 90.9%, 72.7% and 100.0%, respectively. For the remaining microorganisms, predominant bacteriuria was ≤103 CFU/ ml. In pelvic urine, the rates of bacteriuria of ≥104 CFU/ml for E. coli, Klebsiella spp. and Proteus spp. was 71.8%, 40.0% and 66.7%, respectively. Other uropathogens in the pelvic urine mainly had a bacterial count of ≤103 CFU/ml. Only the concentration of Corynebacterium spp. in the pelvic urine significantly (p=0.023) differed from that of the bladder urine. There were no significant differences between microbiota of bladder and pelvic urine depending on duration of OOP except higher rates of Corynebacterium spp. in the bladder urine.

The most common cause of male infertility is idiopathic oligo-, and or astheno-, and /or teratozoospermia. In such cases, anti-estrogens, antioxidants (vitamins and trace elements) or carnitines are used, but the evidence on their effectiveness is inconsistent; there are currently no published studies exploring their concurrent use. Aim. To investigate the efficacy and safety of the L- and acetyl-L-carnitine complex, vitamins A, E, C, selenium, zinc and other antioxidants («SpermActin®» + «More than vitamins»®) in combination with clomiphene citrate (CC) in managing male idiopathic infertility in the form of oligo, and/or astheno-, and/or teratozoospermia. Materials and methods. The study comprised 173 men from infertile couples aged 25-45 years who were divided into two groups - the study group (n=88) and control group (n=85). All the patients were examined according to the WHO recommendations. Patients of the study group received L-carnitine fumarate (1 g), acetyl-L-carnitine (0.5 g) twice daily, a complex of vitamins and microelements and CC 25 mg twice daily orally. Patients of the control group were administered the same dosages of CC and a complex of vitamins. Ejaculate was evaluated before and after 3-4 months of treatment. Six months after the start of treatment, information about the onset or absence of pregnancy over the last six months was collected via telephone or online survey. Results. Co-administration of L- and acetyl-L-carnitines concurrently with CC and antioxidant complex (vitamins and minerals) in patients with idiopathic oligo- and/or asteno- and/or teratozoospermia provides some additional positive effect on the concentration of spermatozoa, more pronounced in patients with multiple impaired semen parameters - oligoasthenoteratozoospermia, but does not improve the morphology, progressive sperm motility and pregnancy rates compared to patients receiving basic treatment.

Aim. To analyze the effectiveness and safety of laparoscopic pyelolithotomy (LP) in treating staghorn stones. Materials and methods. A multicentre retrospective analysis of the results of LP performed from January 2004 to December 2016 was conducted. Inclusion criteria: patients with staghorn calculi K3-K4, who underwent LP as an alternative to percutaneous nephrolithotripsy. The analysis included the incidence and structure of intra- and postoperative complications, the causes of access conversion, operating time, duration of postoperative hospital stay and stone clearance. Results. A total of 137 patients met the inclusion criteria, including 78 (56.93%) men. There was no mortality and access conversion. Intraoperative complications occurred in 2 (1.46%) patients. Operating time was 130 [100; 150] min, blood loss was 150 [100; 200] ml. No need for blood transfusion was observed. The cumulative rate of postoperative complications was 5.11%, stone clearance was achieved in 86.13% of observations, the duration of postoperative hospital stay was 7 [7; 11] days. Conclusion. In cases of dense staghorn calculi located in a large «extrarenal» pelvis and have calyceal branches equal to the diameter of their necks, laparoscopic pyelolithotomy is an alternative not only to open, but also to percutaneous surgery.

Introduction. In recent years, there has been an increasing role of ureteroscopy in managing urinary tract calculi of various locations. Several studies have reported the relationship between the efficacy and safety of ureteroscopic interventions and surgeon’s skills and hospital caseload volume. The aim of our study was to assess the effectiveness of urethroscopic stone removal, the changes in treatment effectiveness, frequency and types of complications along with gaining experience in these interventions. Materials and methods. We analyzed 4031 urolithiasis patients who were admitted to our urological department and underwent ureteroscopy from 2001 to 2013. To determine the effectiveness and safety of the method, as the experience gained, the time of observation was divided into three periods: from 2000 to 2004, from 2004 to 2009, from 2009 to 2013. The parameters were evaluated for the entire observation time and for each period. Results. Complete fragmentation of the stones was observed in 3628 (90%) patients, partial - in 219 (5.4%). No treatment effect was observed in 138 (3.4%) patients. The greatest effectiveness (96.94%) was seen in stones in the lower third of the ureter. The proportion of unsuccessful ureteroscopies was 5.7%, 4.5% and 3.5% for the periods 2000 -2004, 2005-2009 and 2009-2013, respectively (p=0.027). The incidence of acute postoperative pyelonephritis in the corresponding periods was 15.4%, 3.3% and 2.9% (p<0.001). Conclusion. Ureteroscopy is an effective and safe treatment modality for managing upper urinary tract calculi. It is most effective in treating distal ureteral stones. The increase in the treatment effectiveness and the reduction in the incidence of complications along with gaining experience, suggests that these interventions should be practiced mainly in urology centers specializing in the care of patients with urolithiasis.

Introduction. Surgery remains the gold-standard curative treatment for localized (T1) renal carcinoma. However, recent medical-technological advances have led to the development of new minimally invasive treatment options, one of which is percutaneous cryoablation. Aim. To assess the effectiveness and safety of ultrasound-guided percutaneous cryoablation of renal tumors. Materials and methods. The study comprised 12 patients aged 52 to 76 years who underwent ultrasound-guided percutaneous cryoablation of renal tumors from 2015 to 2017. In 11 patients, the size of the renal mass was 3.0 cm (T1a), in 1 patient 4.5 cm (T1b). A Doppler ultrasound, contrast-enhanced MSCT and computer 3D modeling were performed in all patients pre-operatively and 6 months after surgery to assess the tumor’s size and extent and the spatial location of the tumor internal surface to the pelvicalyceal system. In all patients, the tumors were located along the posterior or lateral surface of the kidney, in the lower or middle segment and without sinus invasion. We used a 3rd generation Galil Medical’s SeedNet Gold Cryotherapy System and IceSeed and IceRod cryoprobes. Intraoperatively, immediately before cryoablation, the tumor was biopsied. In all patients the diagnosis of renal cell carcinoma was confirmed morphologically. Results. Mean duration of cryoablation was 60 minutes. Endotracheal, spinal, local and intravenous anesthesia was used in 1, 6, 5 and 1 patients, respectively. Doppler ultrasound at 6 months after surgery showed that in 11 patients (T1a) the tumor size decreased on average by 8 mm, with no blood flow in the tumors. MSCT with 3D modeling also revealed a decrease in tumor size and total absence of contrast agent accumulation, or accumulation gradient not exceeding 10 HU (initially it was about 200 HU). In the patient with T1b stage renal carcinoma, MSCT showed a decrease in tumor size from 4.5 to 3.7 cm, however, there was a mass up to 1.5 cm with a high gradient of contrast agent accumulation. The patient underwent kidney resection. No intra- and postoperative complications were observed. Conclusion. The accumulated experience allows to confirm the effectiveness and safety of ultrasound-guided percutaneous cryoablation and to consider it a method of choice for patients with stage T1a renal carcinoma located along the posterior or lateral surface of the kidney in the lower or middle segment, without sinus invasion.

There are numerous options for forming an orthotopic bladder by the source tissue and the shape of the urinary reservoir. In our practice, we use the technique reported by Karolinska Institute (Sweden). This technique allows us to form a neobladder most resembling the natural urinary bladder in the shape and volume. The article presents a clinical observation describing this technique in a 63 year old patient who was initially diagnosed with bladder cancer pT2N0M0G3 and underwent transurethral resection of the bladder wall with the tumor. Thereafter, the patient underwent laparoscopic cystoprostatvesicleectomy with extended pelvic lymph node dissection and orthotopic ileal bladder substitution. His upper urinary tract on both sides was drained by ureteral stents with external diversion. The eccentric suturing technique makes it possible to form an oval-shaped urinary reservoir that is anatomically and functionally most comparable to a healthy man's bladder.

The article presents a case of laparoscopic antevasal correction of the retrocaval ureter in a 16 year old patient, who was admitted to the hospital with complaints of aching pain in the right lower back. His history was noteworthy of early age onset of intermittent fever accompanied by abdominal and lumbar pain. Blood count and urinalysis were within normal limits, and he was treated symptomatically. However, no renal ultrasound scan was done. Intravenous urography and MSCT showed a retrocaval ureter. The diagnosis was confirmed by retrograde ureteropyelography. With the patient placed in the lateral position, the right ureter was mobilized by transperitoneal access, transected and mobilized from under the inferior vena cava. Anterior uretero-ureteral anastomosis on the stent was performed, drainage was established. The operating time was 90 minutes, blood loss was 60 ml. There were no postoperative complications. Drainage was removed 2 days after surgery and the patient was discharged for outpatient treatment. The stent was removed 6 weeks postoperatively. Control urography showed normal function of both kidneys, no urodynamic abnormality of the upper urinary tract was identified

The «gold standard» for the diagnosis and evaluation of urinary stones is native computed tomography, which allows determining stone localization and size of with high accuracy. However, this imaging technique has limited diagnostic usefulness in determining the stone chemical composition. The newly introduced method of dual-energy computed tomography, based on obtaining images at two different energy levels is highly effective in determining the composition of urinary stones. The review outlines the principles and methods of performing dual-energy computed tomography using various scanners. The authors analyze the results of using this method for diagnosing urolithiasis, determining the stone chemical composition and point out the limitations and difficulties encountered in its application.

The article presents current views on urogenital diseases caused by M. hominis and U. urealyticum. Particular attention is paid to concurrent (co-occurring) urogenital infections. The review reports the data from epidemiological studies and outlines recent Russian and international guidelines and consensuses on managing patients with urogenital inflammatory diseases. The importance of adequate diagnosis and rational therapy of urogenital infections is discussed.

The article provides coverage of the main features of the American Urological Association (AUA) Guideline for the diagnosis and management of male urethral stricture published in 2016. Clinical guideline on this medical condition is published for the first time and is unique in the world of urology. The authors present their comments based on the accumulated experience of diagnosis and treatment of this urological condition.